Remote Utilization Review Rn Jobs in Decatur, GA

Remote Clinical Nurse Auditor
Category: Analytics and Emerging Digital Technologies
Main location: United States, Georgia, Atlanta
Alternate Location(s): United States, North Carolina, Charlotte
United States, Tennessee, Knoxville
Position ID:J0226-0665
Employment Type: Full Time
Position Description:
The Clinical Nurse Auditor is a vital member of the CGI CSG Clinical Audit Team. In this role, you will be responsible for reviewing medical records to determine the medical appropriateness of clinical services rendered to beneficiaries of various health plans, including Commercial and Government Clients, across a variety of care settings.
The Clinical Nurse Auditor is charged with rendering independent, appropriate, well-supported, and thoroughly-documented decisions. These decisions may result in the identification of improper payments on paid claims on behalf of the Client from various Providers, including but not limited to acute care, outpatient, and other Provider types and care settings.
You will be prepared for the role through a detailed, well-defined training process, gaining knowledge and skills in:
Methods for reviewing medical records and provider documentation.
The application of appropriate screening guidelines.
The use of documentation formats tailored to Client requirements.
Ongoing training and education are provided specific to audit processes, clinical procedures, disease states, and other topics. The review process may result in approval or denial of payment for previously-rendered services. Decisions are rendered through a well-defined process requiring the Auditor to incorporate clinical experience, knowledge, and critical thinking skills to assess available information.
The Clinical Nurse Auditor reports to a Clinical Audit Team Leader, who provides support, feedback, and guidance. Audit performance review, Inter-Rater Reliability (IRR), and Performance Measurement (PM) are conducted through a comprehensive quality management program.
Note: This position is remote-friendly (anywhere in the U.S.), provided candidates are willing to work Eastern Time Zone hours.
Your future duties and responsibilities:
Conduct Claim Audits: Perform inpatient and outpatient audits to determine medical necessity, validate prior authorizations, conduct clinical validations, or execute medical service charge audits to recover improper payments.
Rationale Development: Develop clear rationale for audit decisions based on provider information, citing appropriate review guidelines and applicable regulations, and entering documentation into ProperPay.
Physician Referral: Follow designated procedures for referral to a Physician Advisor when required by Client contracts.
Clinical Validation: Document specified coding issues in conjunction with the DRG Validation Team as assigned.
Corporate Compliance: Follow CGI CSG policies, completing mandatory training, timesheets, payroll, and travel expense documents in a timely manner.
Team Communication: Communicate timely with the Team Lead regarding schedule changes, vacation requests, performance barriers, or technical issues.
Quality & Productivity: Comply with department standards regarding audit quality and productivity.
Other Duties: Perform additional tasks as assigned.
Required qualifications to be successful in this role:
Licensure: Registered Nurse (RN) with active, unrestricted licensure in the state of residence.
Clinical Experience: Five or more years of Intensive Care (ICU/CCU) nursing experience is required.
Technical Proficiency: Strong working knowledge of computer functions, Windows operating systems, and Microsoft Office (Outlook, Word, Excel).
Communication Skills: Ability to write well-reasoned reviews in a narrative style with accurate spelling, grammar, punctuation, and sentence structure.
Work Style: Ability to work independently, adapt to changing priorities, and meet strict productivity standards and deadlines.
Travel: Willingness to travel up to 25% for additional training and on-site reviews as needed.
Working Conditions & Commitment
Please note that this is a full-time position requiring a standard 40-hour weekly commitment. Due to the nature of medical record review and detailed clinical documentation, this role involves long periods of sedentary work, including sitting and maintaining focus at a computer workstation for the duration of the shift.
Other Information:
CGI is required by law in some jurisdictions to include a reasonable estimate of the compensation range for this role. The determination of this range includes various factors not limited to skill set, level, experience, relevant training, and licensure and certifications. To support the ability to reward for merit-based performance, CGI typically does not hire individuals at or near the top of the range for their role. Compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range for this role in the U.S. is $52,200.00 - $114,900.00.
CGI's benefits are offered to eligible professionals on their first day of employment to include:
. Competitive compensation
. Comprehensive insurance options
. Matching contributions through the 401(k) plan and the share purchase plan
. Paid time off for vacation, holidays, and sick time
. Paid parental leave
.Learning opportunities and tuition assistance
. Wellness and Well-being programs
What you can expect from us:
Together, as owners, let's turn meaningful insights into action.
Life at CGI is rooted in ownership, teamwork, respect and belonging. Here, you'll reach your full potential because...
You are invited to be an owner from day 1 as we work together to bring our Dream to life. That's why we call ourselves CGI Partners rather than employees. We benefit from our collective success and actively shape our company's strategy and direction.
Your work creates value. You'll develop innovative solutions and build relationships with teammates and clients while accessing global capabilities to scale your ideas, embrace new opportunities, and benefit from expansive industry and technology expertise.
You'll shape your career by joining a company built to grow and last. You'll be supported by leaders who care about your health and well-being and provide you with opportunities to deepen your skills and broaden your horizons.
Come join our team-one of the largest IT and business consulting services firms in the world.
Qualified applicants will receive consideration for employment without regard to their race, ethnicity, ancestry, color, sex, religion, creed, age, national origin, citizenship status, disability, pregnancy, medical condition, military and veteran status, marital status, sexual orientation or perceived sexual orientation, gender, gender identity, and gender expression, familial status or responsibilities, reproductive health decisions, political affiliation, genetic information, height, weight, or any other legally protected status or characteristics to the extent required by applicable federal, state, and/or local laws where we do business.
CGI provides reasonable accommodations to qualified individuals with disabilities. If you need an accommodation to apply for a job in the U.S., please email the CGI U.S. Employment Compliance mailbox at US_Employment_Compliance@cgi.com. You will need to reference the Position ID of the position in which you are interested. Your message will be routed to the appropriate recruiter who will assist you. Please note, this email address is only to be used for those individuals who need an accommodation to apply for a job. Emails for any other reason or those that do not include a Position ID will not be returned.
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All CGI offers of employment in the U.S. are contingent upon the ability to successfully complete a background investigation. Background investigation components can vary dependent upon specific assignment and/or level of US government security clearance held. Dependent upon role and/or federal government security clearance requirements, and in accordance with applicable laws, some background investigations may include a credit check. CGI will consider for employment qualified applicants with arrests and conviction records in accordance with all local regulations and ordinances.
CGI will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with CGI's legal duty to furnish information.